8 Non-pharmacological treatments

8.1 Ketogenic diet

8.1.1 Consider a ketogenic diet under the guidance of a tertiary epilepsy specialist, in people with:

  • certain childhood-onset epilepsy syndromes (see also the section on treating childhood-onset epilepsies), for example:

    • glucose transporter type 1 deficiency syndrome (GLUT1 deficiency syndrome)

    • epilepsy associated with pyruvate dehydrogenase deficiency

    • infantile spasms syndrome

    • epilepsy with myoclonic-atonic seizures (Doose syndrome)

    • Dravet syndrome

    • Lennox–Gastaut syndrome

  • drug-resistant epilepsy if other treatment options have been unsuccessful or are not appropriate.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on ketogenic diet.

Full details of the evidence and the committee's discussion are in evidence review 12: ketogenic diets for drug-resistant epilepsy.

8.2 Resective epilepsy surgery

Referral for resective epilepsy surgery assessment

8.2.1 Discuss the options for assessment for resective epilepsy surgery with people who have drug-resistant epilepsy, and their families or carers if appropriate. Explain what the process of surgical assessment involves as well as the benefits and risks associated with surgical procedures.

8.2.2 Refer people with drug-resistant epilepsy, including those without identified MRI abnormalities, for consideration of assessment for resective epilepsy surgery:

  • For adults, this should be to a tertiary epilepsy service.

  • For children and young people, this should be to a tertiary paediatric neurology service for consideration of referral to a children's epilepsy service surgery centre.

8.2.3 For people with MRI abnormalities that indicate a high risk of drug-resistant epilepsy, consider early referral to a tertiary epilepsy service for assessment, including an evaluation for resective epilepsy surgery if appropriate. Examples of specific lesions seen on MRI may include, but are not limited to, the following:

  • hippocampal sclerosis

  • malformations of cortical development

  • epilepsy-associated low-grade tumours

  • hypothalamic hamartomas

  • neuronal migrational disorders

  • tuberous sclerosis complex

  • vascular malformations, including Sturge–Weber syndrome

  • cerebral contusions from previous head injury.

8.2.4 Do not exclude people with learning disabilities or underlying genetic abnormalities from referral for resective epilepsy surgery assessment if it is indicated.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on resective epilepsy surgery.

Full details of the evidence and the committee's discussion are in evidence review 13: referral and surgical interventions.

8.3 Vagus nerve stimulation

8.3.1 If resective epilepsy surgery is not suitable for a person with drug-resistant seizures, consider vagus nerve stimulation as an add-on treatment to antiseizure medication. See also NICE's interventional procedures guidance on vagus nerve stimulation for refractory epilepsy in children.

8.3.2 Discuss with the person with epilepsy, and their family or carers if appropriate, the benefits and risks of vagus nerve stimulation before making a shared decision about having this procedure.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on vagus nerve stimulation.

Full details of the evidence and the committee's discussion are in evidence review 14: vagus nerve stimulation.

  • National Institute for Health and Care Excellence (NICE)